19 November 2013

Chaotic capers at Canberra Hospital. Shame they cost a life

| johnboy
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There’s an ABC story up about the inquest into the death of Suki Thurairajah who went to Canberra Hospital for dialysis and didn’t make it out alive.

First year registrar Clare Thomsett put an air tube down the wrong hole while working unassisted:

Today the doctor who incorrectly inserted the tube, first-year anaesthetics registrar Clare Thomsett, told the coronial inquest that she had not been assisted in inserting the tube as is required.

She said as a result, she had to remove a light she was holding that gave a view of the vocal chords and the correct passage of the tube down the throat.

Dr Thomsett also said communication in the emergency team was chaotic and the roles of the emergency team members were not made clear by the senior doctor present.

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Deref said :

Did I hear it correctly – that she was a first year student?

No – I didn’t. She was a first-year registrar. Sorry. 🙁

BimboGeek said :

The registrar is right to speak up and tell the truth, that she was put in a position where she didn’t know what she was doing and didn’t even have anyone to check her work. These guys are smart, they shouldn’t have to learn from this kind of mistake!

Hear, hear.

Did I hear it correctly – that she was a first year student?

ScienceRules4:08 pm 20 Nov 13

gazket said :

Sadly Suki Thurairajah isn’t the only person to die from malpractice. I’m surprised the hospital even owned up to the mistake.
I had friend die at Woden last year went in for a simple operation found dead a few hours later , nothing has happened about it.

The Coroner wasn’t interested at all?

Sadly Suki Thurairajah isn’t the only person to die from malpractice. I’m surprised the hospital even owned up to the mistake.
I had friend die at Woden last year went in for a simple operation found dead a few hours later , nothing has happened about it.

BimboGeek said :

The registrar is right to speak up and tell the truth, that she was put in a position where she didn’t know what she was doing and didn’t even have anyone to check her work. These guys are smart, they shouldn’t have to learn from this kind of mistake!

That might well be, and I agree she should be drawing attention to shortcomings. But she hasn’t done her career prospects any good by telling the truth.

Medicine is a closed shop with a very strict hierarchy.

ScienceRules2:43 pm 20 Nov 13

Pitchka said :

How does one get her medical degree, surely putting an air tube down the wrong hole is far from a complex error.

It’s not that simple, Pitchka. Intubation (putting a tube into the airway) isn’t straightfoorward as every airway is different, some are very difficult to visualise (they might be full of blood, mucous etc) or the anatomy of the patient makes it hard or impossible to visualise the landmarks you need to do the job.

On top of which, the patient isn’t actually breathing or being oxygenated while the procedure is carried out, so it’s more than a bit stressful under emergency conditions.

How does one get her medical degree, surely putting an air tube down the wrong hole is far from a complex error.

This is not the first time someone went to hospital for dialysis and didn’t survive. My friend was apparently transferred to emergency and bled internally over a couple of hours due to bungling… By the time emergency figured out what happened it was all too late.

Same problem: unsupervised numpty doing the operation, unsupervised numpties trying to save him. It’s hard to get over this kind of death, even now 4 years later I just get super furious thinking about the whole stupid mess.

The registrar is right to speak up and tell the truth, that she was put in a position where she didn’t know what she was doing and didn’t even have anyone to check her work. These guys are smart, they shouldn’t have to learn from this kind of mistake!

http://static.shop033.com/resources/4E/5966/picture/1B/82273307.jpg

Not wanting to be flippant about it, and I’m sure this story doesn’t tell the whole story, but seriously…nobody there to hold the light?!

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